J Cardiol 2007 May; 49（5）: 221 – 229

Volume Measurement of the Left
Ventricle in Children Using RealTime Three-Dimensional Echocardiography: Comparison With Ventriculography
Mayu

IINO, MD

Hirohiko

SHIRAISHI, MD, FJCC

Kou

ICHIHASHI, MD, FJCC

MasaruHOSHINA, MD

Mari

SAITOH, MD

Yuka

HIRAKUBO, MD

Yasuko

MORIMOTO, MD

Mariko Y.

MOMOI, MD

Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
Objectives. Recently, a real-time three-dimensional echocardiography（RT3DE）volume scanning technique was developed and used clinically. For precise ventricular volumetry, independent of mathematicalassumptions, imaging techniques such as three-dimensional echocardiography are required in children withheart disease. This study evaluated whether RT3DE is suitable for left ventricular volumetry in children,
and whether left ventricular volumes measured by RT3DE correlate sufficiently well with those measured
by left ventriculography（LVG）.
Methods. Twenty-five children with heart disease, 17 boys and 8 girls aged from 8 months to 18 years（mean age 5.9 ± 5.3 years）, underwent cardiac catheterization at our institution. RT3DE was performed
within 30 min after LVG using the Philips SONOS 7500 ultrasound system with an electronic sector probe
consisting of a × 4 matrix phased array transducer（center frequency of 2−4 MHz）. Ultrasound images ofthe ventricle were calculated offline using TomTec 4D Cardio-View RT 1.2 software. Left ventricular volumes by LVG were calculated using Siemens Hicor T.O.P. Finally, the left ventricular volumes by RT3DE
and LVG were compared.
Results. Left ventricular volumes measured by RT3DE correlated and agreed well with those measured
by LVG（r ＝ 0.996, Y ＝ 0.566 ＋ 0.964 X, mean difference −0.29 ± 1.90 ml ; left ventricular end-systolicvolume, r ＝ 0.979, Y ＝−0.187 ＋ 0.897 X, mean difference −6.76 ± 10.58 ml ; left ventricular end-diastolic volume）.
Conclusions. RT3DE is suitable for left ventricular volumetry in children. There was a good correlation
between RT3DE and LVG, but the volume of left ventricular end-diastolic volume estimated by RT3DE
was smaller than that by LVG.
─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2007 May; 49（5）: 221−229

Key Words（three-dimensional）■ Echocardiography, transthoracic（ventriculography）■ Angiocardiography■ Pediatric cardiology（measurement）■ Cardiac volume──────────────────────────────────────────────
自治医科大学 小児科 : 〒 329−0498 栃木県下野市薬師寺 3311−1
Department of Pediatrics, Jichi Medical University, Tochigi
Address for correspondence : IINO M, MD, Department of Pediatrics, Jichi Medical University, Yakushiji 3311− 1, Shimotsuke,
Tochigi 329 − 0498 ; E-mail : miino@jichi.ac.jp
Manuscript received January 5, 2007 ; revised February 8, 2007 ; accepted February 13, 2007

221

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Iino, Shiraishi, Ichihashi et al

Table 1 Patients investigated in this study

INTRODUCTION
Volume measurement of the left ventricle is necessary to evaluate cardiac function and is currently
performed using two-dimensional echocardiography（2DE）or angiocardiography. Echocardiography is an inexpensive, noninvasive, portable,
and easily repeatable modality for evaluating cardiac function in comparison with angiocardiography, although the 2D echocardiographic measurement of ventricular volume is limited by assumptions of ventricular geometry and image positioning. More accurate ventricular volume measurement using three-dimensional echocardiography（3DE）
will mark a new step in pediatric cardiovascular diagnosis and treatment.1−6）
Recently, a real-time three-dimensional echocardiography（ RT3DE）volume scanning technique
was developed and used clinically.7−14）However,there are insufficient data with regard to the feasibility, accuracy and reproducibility of measuringleft ventricular volumes using this system, andcomparing and validating RT3DE measurementswith other established modalities, such as left ventriculography（LVG）
in children.15 −24）
This study evaluated whether RT3DE is suitable
for left ventricular volumetry in children, andwhether left ventricular volumes measured by
RT3DE correlate sufficiently well with those measured by LVG.
SUBJECTS AND METHODSPatient data
Twenty-five children with heart disease, 17 boys
and 8 girls aged from 8 months to 18 years（mean
age 5.9 ± 5.3 years）, underwent cardiac catheterization at our institution. The indications for cardiac
catheterization were pre- and post-operative assessment of cardiac anatomy and hemodynamics inpatients with known congenital heart disease orassessment of coronary lesion in patients with
Kawasaki disease, arteritis and chest pain（Table1）. Informed consent was obtained from the parents.
Real-time three-dimensional echocardiographic
data
RT3DE was performed within 30 min after LVG.
To confirm essentially unchanged hemodynamics,
the scan immediately followed the cardiac catheter
investigation, which was performed with patients in

n＝25

Heart disease
Patent ductus arteriosus

6

Ventricular septal defect5

Atrial septal defect5

Kawasaki disease5

Tetralogy of Fallot post intracardiac repair

1

Cor triatrium

1

Takayasu arteritis

1

Chest pain

1

Twenty-five children（mean age 5.3±5.9 years, 17 boys and 8
girls）with heart disease were prospectively enrolled.

the supine position. Depending on the location for
ideal imaging quality, the transducer was positioned
apically.
The ultrasonic diagnostic equipment used in thisstudy was SONOS 7500
（Philips Medical Systems）
with an electronic sector probe consisting of a × 4
Matrix phased array transducer（center frequency of
2−4 MHz）. The × 4 Matrix phased array houses
3,000 elements and a conical volumetric data set
can be acquired. The images were optimized using
the biplane mode to visualize all left ventricular
epicardial and endocardial contours. For a full volume image, a large conical 3D data set with a fieldof view of 90 × 90 degrees was acquired. The fullvolume data set was compiled from four 23 × 90
degree subvolumes with electrocardiography（ECG）
triggering and the acquisition time was about 3−4
sec（4 beats）with the full cycle on mode. All data
sets were saved onto a hard disk drive, and thendownloaded to compact disks for offline
analysis.10−14, 25, 26）
Ultrasound images of the ventricle were calculated offline using 4D Cardio-View RT 1.2 software（TomTec Imaging Systems GmbH）. The software
includes the average rotation method which can set
up a central shaft and trace the long-axis plane. The
software can calculate from the upper to the lower
plane areas by integral calculus, and the accuracyof this method is reported to be greater than that ofSimpson s method using 2DE.11）This software cancalculate ventricular volumes using two, four, eight,
and sixteen cut planes. Images of the left ventricle
were calculated using four and eight cut planes inthis study. The 3D data set was displayed in a 4tiled image screen. The two upper images werelong-axis images, and the left lower image was a
J Cardiol 2007 May; 49（5）: 221 – 229

Pediatric Volume Measurement by 3D Echocardiography

223

Fig. 1 Offline analysis of real-time three-dimensional echocardiography data
The data set is displayed in a 4-tiled image screen. The two upper images are long-axis images, and the left
lower image is a short-axis image. Left ventricular endocardial borders were traced manually after fine tuning
at end-systole and end-diastole. Four slices of the left ventricle along the long axis were obtained from ashort-axis reference image at 45-degree increments around a 180-degree plane on four cut planes. The rightlower images are left ventricular end-systolic（blue）and end-diastole（orange）volumes.
LVEDV ＝ left ventricular end-diastolic volume ; LVESV ＝ left ventricular end-systolic volume.

short-axis image. Left ventricular endocardial borders were traced manually after fine-tuning at endsystole and end-diastole. Left ventricular volumes
and ejection fraction were calculated using an interactive splice algorithm with software for the rightlower image. 27）Four slices of the left ventricle
along the long axis were obtained from short-axis
reference images at 45-degree increments around a
180-degree plane on four cut planes, and eightslices of the left ventricle along the long axis wereobtained from short-axis reference images at 22.5degree increments around a 180-degree plane oneight cut planes. Volumes of the left ventricle were
calculated using an interactive splice algorithmwith software（Fig. 1）. The image at the QRS complex of the simultaneously registered ECG was
selected as the end-diastolic condition and the firstimage after closure of the aortic valve was selected
to represent the end-systolic state. The endocardial
borders were traced manually on the end-diastolicand end-systolic images. The papillary muscles
were included within the left ventricular cavity
inseparable from the myocardium.

J Cardiol 2007 May; 49（5）: 221 – 229

Angiocardiographic data
All younger children were investigated underdeep sedation（thiopental sodium）, whereas older
patients, usually over the age of 10 years, received
local anesthesia with lidocaine hydrocholoride. For
most patients, complete assessment of hemodynamics was undertaken, including pressure measurement and oxymetry. Left ventriculograms were registered simultaneously on right anterior oblique（30degree）and left lateral oblique（60-degree）films.
Contrast medium ranging from 1 to 1.5 ml / kg
was selectively injected into the left ventricularwithin 2 sec using a Pigtail catheter（CX catheter ;Cathex Limited）
inserted into the femoral artery.
The image at the QRS complex of simultaneously registered ECG was selected as the end-diastoliccondition and the first image after closure of theaortic valve was selected to represent the end-systolic state. On the end-diastolic and end-systolic
images, the endocardial borders were traced manually on right anterior oblique films, and the data
were fed into a computer program for analysis
（Fig.
2）
.
Left ventricular volumes were calculated by thearea-length s rule using Hicor T.P.O.（Siemens224

Iino, Shiraishi, Ichihashi et al

Fig. 2 Analysis of left ventriculography data on right anterior oblique films
The left side shows a left ventricular end-diastolic image and the right side shows an endsystolic image. Left ventricular endocardial borders were traced manually to calculate left
ventricular volumes and ejection fraction. Left ventricular ejection fraction ＝ 64%. Strokevolume ＝ 24.7 ml. Left ventricular end-diastolic volume ＝ 38.6 ml. Left ventricular end-systolic volume ＝ 13.9 ml.

AG）. The longitudinal ventricular axis was defined
between the middle of the aortic valve and the ventricular apex. The papillary muscles were included
within the left ventricular cavity inseparable fromthe myocardium.
Statistical analysis
Measurements of left ventricular end-systolicvolume（LVESV）, left ventricular end-diastolic volume（LVEDV）, and left ventricular ejection fraction（LVEF）by RT3DE were analyzed using left
ventriculographic measurements as the reference
standard. To examine the correlation and agreement
between the two sets of measurement, linear regression analysis and the Bland-Altman method wereused.28, 29）
Inter- and intraobserver variability
To test the variability in ventricular volume calculations using RT3DE, the first observer（M.I.）
andthe second observer（H.S.）, who were both unawareof previous results, repeated randomly selected
RT3DE calculations. Variability was expressed as
the difference of the mean of the two results, as apercentage of the mean.
RESULTS
Data for RT3DE and LVG were acquired successfully for analysis. Measurements of LVESV
using RT3DE correlated and agreed well with LVG,
but LVEDV measurements using RT3DE were

smaller than those of LVG.
Figs. 3−7 show linear regression analysis andthe Bland-Altman method of LVESV, LVEDV,LVEF using RT3DE and LVG measurements.
There was good correlation and agreement in themeasurement of LVESV（Y ＝ 0.566 ＋ 0.964 X, r ＝0.996, mean difference −0.29 ± 1.90 ml ; four cut
planes, Y ＝ 0.618 ＋ 0.983 X, r ＝ 0.995, mean difference 0.22 ± 1.95 ml ; eight cut planes）between
RT3DE and LVG（Figs. 3, 4）. There was also goodcorrelation in LVEDV（Y ＝−0.187 ＋ 0.897 X, r ＝0.979 ; four cut planes, Y ＝−0.631 ＋ 0.926 X, r ＝0.982 ; eight cut planes）. However, there wasunderestimation of the LVEDV（mean difference−6.76 ± 10.58 ml ; four cut planes, −5.34 ±9.64 ml ; eight cut planes）between RT3DE and
LVG（Figs. 5, 6）. There was loose correlation in
LVEF（Y ＝ 17.552 ＋ 0.66 X, r ＝ 0.686, mean difference −3.26 ± 4.22% ; four cut planes, Y ＝20.779 ＋ 0.612 X, r ＝ 0.627, −3.19 ± 4.62% ;eight cut planes）（Fig. 7）using RT3DE comparedwith LVG measurements.
Interobserver variability of RT3DE measurements was : 14% for LVESV ; 8% for LVEDV ;and 3% for LVEF on four cut planes, 16% for
LVESV ; 9% for LVEDV ; and 12% for LVEF oneight cut planes. Intraobserver variability of
RT3DE measurements was : 7% for LVESV ; 3%for LVEDV ; and 6% for LVEF on four cut planes,
6% for LVESV ; 2% for LVEDV ; and 7% for
LVEF on eight cut planes.
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Pediatric Volume Measurement by 3D Echocardiography

225

Fig. 3 Linear regression analysis of left ventricular end-systolic volumes by left ventriculography
and real-time three-dimensional echocardiography
RT3DE ＝ real-time three-dimensional echocardiography ; LVG ＝ left ventriculography. Other abbreviation as in Fig. 1.

Fig. 4 Bland-Altman method of left ventricular end-systolic volumes by left ventriculography andreal-time three-dimensional echocardiography
Abbreviations as in Figs. 1, 3.

DISCUSSION
This study demonstrated that RT3DE measurements of left ventricular volumes in children withheart disease using a full-volume acquisition strategy are accurate and comparable with angiographic
measurements. RT3DE can provide accurate volume measurement of the left ventricle in children.
Linear regression analysis and the Bland-Altman
method showed good correlation and agreement
using RT3DE compared with LVG.
3DE is not dependent on left ventricular geomeJ Cardiol 2007 May; 49（5）: 221 – 229

try and is superior to 2DE for measurements of left
ventricular indexes.1−6）Conventional 2D echocardiographic measurement of ventricular volume islimited by assumptions of ventricular geometry andimage positioning, and is reported to underestimate
left ventricular volume.8）There are many clinicalconditions in children with congenital heart diseases in which left ventricular geometry is alteredsignificantly, which leads to erroneous measurements of left ventricular indexes by M-mode and2DE methods. The software used in our study has
an average rotation method that can set up a central

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Iino, Shiraishi, Ichihashi et al

Fig. 5 Linear regression analysis of left ventricular end-diastolic volumes by left ventriculography
and real-time three-dimensional echocardiography
Abbreviations as in Figs. 1, 3.

Fig. 6 Bland-Altman method of left ventricular end-diastolic volumes by left ventriculography andreal-time three-dimensional echocardiography
Abbreviations as in Figs. 1, 3.

shaft and can trace the long-axis plane, and thencalculate upper from lower plane areas using integral calculus. The accuracy of this method isreported to be greater than that of Simpson s
method with 2DE.10−14）Quantititative RT3DE has
been applied for left ventricular volumes and functions in humans, animals and phantom models ofadults.6,7,9,10,30）We studied the volume measurementof a pediatric ventricular model using 3DE.
Experimental studies demonstrated that calculation
by manual tracing of the interior surface is the best
method for accurate volume measurement. 25,26）

Accordingly, the endocardial borders were traced
manually for accurate left ventricular volume measurement.
Previous studies assessed left ventricular indexes
using RT3DE compared with quantitative gated single-photon emission computed tomography（QGSPECT）in adults.6,10）RT3DE correlated wellwith QGSPECT in the measurement of LVEDV
and LVESV（r ＝ 0.97, mean difference 3.4 ml for
LVEDV, r ＝ 0.98, mean difference 2 ml for
LVESV）, and LVEF obtained by RT3DE had good
agreement with that obtained by QGSPECT（r ＝J Cardiol 2007 May; 49（5）: 221 – 229

Pediatric Volume Measurement by 3D Echocardiography

227

Fig. 7 Bland-Altman method of left ventricular ejection fraction by left ventriculography and realtime three-dimensional echocardiography
LVEF ＝ left ventricular ejection fraction. Other abbreviations as in Figs. 1, 3.

0.92, mean difference−0.2%）in patients with wallmotion abnormality.10）However, the measurementof left ventricular indexes using QGSPECT is not
currently used in children. Therefore, QGSPECT
could not be used as the reference standard for themeasurement of left ventricular volume in ourstudy.
In our study, children aged 8 months to 18 years
were investgated. In previous comparative studies
using magnetic resonance imaging（MRI）, patientsneeded to be kept quiet and to achieve prolonged
breath holding during MRI.7,9,13,14,30）Infants who
are not cooperative and cannot hold their breath
may need sedation and possibly endotracheal intubation during MRI, and patients with a cardiac
pacemaker are contraindicated for MRI. Therefore,
MRI cannot be used as the first-line modality forthe assessment of left ventricular volume in children, and could not be used as the reference standard for the measurement of left ventricular volume
in our study. Measurements of LVESV, LVEDV,
mass, stroke volume and LVEF by RT3DE correlated well（r ＝ 0.86−0.97, p ＜ 0.001）
and agreed well14）with MRI in children. However, only children
aged 6 to 18 years were enrolled in that study. In
our study, RT3DE was applied in much younger
children.
The measurement of left ventricular volumeusing angiocardiography is the standard method,especially in children with congenital heart disease.16）Therefore, we compared left ventricularvolumes using RT3DE with those measured using
J Cardiol 2007 May; 49（5）: 221 – 229

angiocardiography, the reference standard, to determine its feasibility, accuracy, and reproducibility.
Volume measurement of the left ventricle（ 10−80 ml）by RT3DE was correlated with LVG in an
animal study.9）We measured a wide range of pediatric hearts in children aged 8 months to 18 years.
Our study estimated volume measurements of small
to moderate left ventricular volumes（5−200 ml）,
and demonstrated that RT3DE is feasible, accurate
and reproducible to measure left ventricular volumes in children.
In our study, there was good correlation andagreement between the measurements of LVESV
using RT3DE and LVG. However, measurements of
LVEDV using RT3DE were smaller than LVG.
Previous studies demonstrated a tendency to underestimate left ventricular volumes by 3DE comparedwith MRI or angiocardiography.12,14）There are various reasons for the underestimation of LVEDV
using RT3DE in our study. First, the patient s respiratory movement was difficult to control to acquire
RT3DE images just after LVG. Second, the transducer was positioned in only an apical acoustic
window. Technically, to acquire an RT3DE data set,
the whole left venticular cavity could not always beplaced within the image angle. This may also contribute to the underestimation of LVEDV by
RT3DE in our study.
There are several limitations in this study. First,
it was performed under anesthesia for catheterization under static conditions. When we measure ventricular volume in daily examination, we must con-

228

Iino, Shiraishi, Ichihashi et alsider the effect of patient movement. Second, theonly available RT3DE transducer had an operating
frequency of 2−4 MHz. To acquire images withsuperior quality and to measure more accurately,
harmonic imaging or intracardiac contrast injection
may enhance endocardial border delineation. Third,
current ECG trigging is necessary for a full volumedata set from four subvolumes that may potentiallycause data discontinuity between the four individual data sets due to breathing, patient movement, or
arrhythmia. Finally, the software in our study
要required manual tracing of the endocardial boundaries. The introduction of automated border detection, if accurate, would make this technique evenmore attractive in the future.
CONCLUSIONS
RT3DE is feasible for volumetry of the left ventricle in most children. There was good correlation
between RT3DE and LVG. The volumes of LVEDV
measured by RT3DE may be smaller than thosemeasured by LVG.
約

リアルタイム 3D 心エコー図法による小児の左室容積計測: 左室造影法との比較

目

飯野

眞由

白石裕比湖

市 橋

光

齋藤

真理

平久保由香

森本

康子

保 科

優

桃井真里子

的 : 近年，リアルタイム 3D 心エコー図法による心腔容積計測が臨床応用されるようになってきた．3D 心エコー図法を用いて心室形態に依存しない正確な心腔容積計測ができれば，とくにさまざまな心室形態を有する心疾患児において極めて有用となる．そこで 3D 心エコー図法による
左室容積計測が小児において臨床応用可能か否かを明らかにする目的で，3D 心エコー図法と心臓カテーテル検査・左室造影法による測定値が一致するか否かを検討した．
方

法 : 対象は，当院小児科に心臓カテーテル検査目的で入院した 8 ヵ月から 18 歳までの 25 例

（平均年齢 5.9 ± 5.3 歳，男 17 例，女 8 例）である．心臓カテーテル検査・左室造影後 30 分以内に 3D
心エコー図検査を実施し画像を記録した．超音波装置は Philips 製 SONOS7500 で 2−4 MHz の電子セ
クタプローブを使用した．記録した 3D 画像から TomTec 製 4D Cardio-View RT1.2 解析ソフトを用いて左室容積を計測した．左室造影法による左室容積は Siemens 製 Hicor T.O.P を用いて計測した．
3D 心エコー図法で計測した左室容積を左室造影法と比較した．
結果 : 3D 心エコー図法で計測した左室容積は，左室造影法で求めた左室容積と相関性が高く，とくに収縮末期でよく一致した（左室収縮末期容積 : Y ＝ 0.566 ＋ 0.964 X ，相関係数 r ＝ 0.996 ，誤差−0.29 ± 1.90 ml，左室拡張末期容積 : Y ＝−0.187 ＋ 0.897 X，相関係数 r ＝ 0.979，誤差−6.76 ±10.58 ml）．
結論 : 3D 心エコー図法による左室容積計測は，心臓カテーテル検査・左室造影法との相関性が高く，小児において有用な検査法であるが，拡張末期容積については心エコー図法による計測値
は左室造影法に比べ小さかった．

J Cardiol 2007 May; 49（5）: 221−229

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